As a provider working with pregnant patients, it is important for you to know the ways in which each STD can impact a woman and her developing baby. The following sections provide details on the effects of specific STDs during a woman’s pregnancy, as well as links to additional information.
Bacterial Vaginosis
Bacterial vaginosis (BV), a common cause of vaginal discharge in women of childbearing age, is a polymicrobial clinical syndrome resulting from a change in the vaginal community of bacteria. Although BV is often not considered an STD, it has been linked to sexual activity. Women may have no symptoms or may complain of a foul-smelling, fishy, vaginal discharge. BV during pregnancy has been associated with serious pregnancy complications, including premature rupture of the membranes surrounding the baby in the uterus, preterm labor, premature birth, chorioamnionitis, as well as endometritis.8 While there is no evidence to support screening for BV in pregnant women at high risk for preterm delivery,21 symptomatic women should be evaluated and treated. There are no known direct effects of BV on the newborn.
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Chlamydia
Chlamydia is the most common sexually-transmitted bacterium in the United States.4 Although the majority of chlamydial infections (including those in pregnant women) do not have symptoms, infected women may have abnormal vaginal discharge, bleeding after sex, or itching/burning with urination. Untreated chlamydial infection has been linked to problems during pregnancy, including preterm labor, premature rupture of membranes, and low birth weight.5 The newborn may also become infected during delivery as the baby passes through the birth canal. Exposed newborns can develop eye and lung infections.
Gonorrhea
Gonorrhea is a common STD in the United States. Untreated gonococcal infection in pregnancy has been linked to miscarriages, premature birth and low birth weight, premature rupture of membranes, and chorioamnionitis.6 Gonorrhea can also infect an infant during delivery as the infant passes through the birth canal. If untreated, infants can develop eye infections. Because gonorrhea can cause problems in both the mother and her baby, it is important for providers to accurately identify the infection, treat it with effective antibiotics, and closely follow up to make sure that the infection has been cured.
Hepatitis B
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). A mother can transmit the infection to her baby during pregnancy. While the risk of an infected mother passing HBV to her baby varies, depending on when she becomes infected, the greatest risk happens when mothers become infected close to the time of delivery.14 Infected newborns also have a high risk (up to 90%) of becoming chronic HBV carriers themselves.15 Infants who have a lifelong infection with HBV are at an increased risk for developing chronic liver disease or liver cancer later in life. Approximately 25% of infants who develop chronic HBV infection will eventually die from chronic liver disease.13 By screening your pregnant patients for the infection and providing treatment to at-risk infants shortly after birth, you can help prevent mother-to-child transmission of HBV. Information on mother-to-child transmission of HBV can be found at https://www.cdc.gov/hepatitis/HBV/PerinatalXmtn.htm.
Hepatitis C
Hepatitis C is a liver infection caused by the hepatitis C virus (HCV), and can be passed from an infected mother to her child during pregnancy. In general, an infected mother will transmit the infection to her baby 10% of the time, but the chances are higher in certain subgroups, such as women who are also infected with HIV.16 In some studies, infants born to HCV-infected women have been shown to have an increased risk for being small for gestational age, premature, and having a low birth weight.15 Newborn infants with HCV infection usually do not have symptoms, and a majority will clear the infection without any medical help.
Herpes Simplex Virus
Herpes Simplex Virus (HSV) has two distinct virus types that can infect the human genital tract, HSV-1 and HSV-2. Infections of the newborn can be of either type, but most are caused by HSV-2. Generally, the symptoms of genital herpes are similar in pregnant and in nonpregnant women; however, the major concern regarding HSV infection relates to complications linked to infection of the newborn. Although transmission may occur during pregnancy and after delivery, the risk of transmission to the neonate from an infected mother is high among women who acquire genital herpes near the time of delivery and low among women with recurrent herpes or who acquire the infection during the first half of pregnancy.18 HSV infection can have very serious effects on newborns, especially if the mother’s first outbreak occurred during the third trimester. Cesarean section is recommended for all women in labor with active genital herpes lesions or early symptoms, such as vulvar pain and itching.19-20
Human Immunodeficiency Virus
Human immunodeficiency virus (HIV) is the virus that causes acquired immune deficiency syndrome (AIDS). HIV destroys specific blood cells that are crucial to helping the body fight diseases. According to CDC’s HIV surveillance data, women make up 19% of all new HIV diagnoses in the United States and dependent areas.2 The most common ways that HIV passes from mother to child are during pregnancy, childbirth, or breastfeeding. However, when HIV is diagnosed before or early during pregnancy and appropriate steps are taken, the risk of mother-to-child transmission can be less than 1%.3 A mother who knows early in her pregnancy that she has HIV has more time to consult with you—her healthcare provider—and decide on effective ways to protect her health and that of her unborn baby.
Human Papillomavirus
Human papillomaviruses (HPV) are viruses that most commonly involve the lower genital tract, including the cervix, vagina, and external genitalia. Genital warts frequently increase in number and size during pregnancy. Genital warts often appear as small cauliflower-like clusters which may burn or itch. If a woman has genital warts during pregnancy, you may elect to delay treatment until after delivery. When large or spread out, genital warts can complicate a vaginal delivery. In cases where there are large genital warts that are blocking the birth canal, a cesarean section may be recommended. Infection of the mother may be linked to the development of laryngeal papillomatosis in the newborn—a rare, noncancerous growth in the larynx .17
Syphilis
Syphilis is primarily a sexually-transmitted disease, but it may be transmitted to a baby by an infected mother during pregnancy. Transmission of syphilis to a developing baby can lead to a serious multisystem infection, known as congenital syphilis. Recently, there has been a sharp increase in the number of congenital syphilis cases in the United States. Syphilis has been linked to premature births, stillbirths, and, in some cases, death shortly after birth.7 Untreated infants that survive tend to develop problems in multiple organs, including the brain, eyes, ears, heart, skin, teeth, and bones.
Trichomoniasis
Vaginal infection due to the sexually-transmitted parasite Trichomonas vaginalis is very common. Although most people report no symptoms, others complain of itching, irritation, unusual odor, discharge, and pain during urination or sex. If you have a pregnant patient with symptoms of trichomoniasis, she should be evaluated for Trichomonas vaginalis and treated appropriately. Infection in pregnancy has been linked to premature rupture of membranes, preterm birth, and low birth weight infants.12 Rarely, the female newborn can acquire the infection when passing through the birth canal during delivery and have vaginal discharge after birth.
Screening and prompt treatment are recommended at least annually for all HIV-infected women, based on the high prevalence of T. vaginalis infection, the increased risk of pelvic inflammatory disease (PID) associated with this infection, and the ability of treatment to reduce genital tract viral load and vaginal HIV shedding. This includes HIV-infected women who are pregnant, as T. vaginalis infection is a risk factor for vertical transmission of HIV. For other pregnant women, screening may be considered at the discretion of the treating clinician, as the benefit of routine screening for pregnant women has not been established.22 Screening might be considered for persons receiving care in high-prevalence settings (e.g., STD clinics or correctional facilities) and for asymptomatic persons at high risk for infection. Decisions about screening might be informed by local epidemiology of T. vaginalis infection. However, data are lacking on whether screening and treatment for asymptomatic trichomoniasis in high prevalence settings or persons at high risk can reduce any adverse health events and health disparities or reduce community burden of infection.20
STD Treatment during Pregnancy
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STDs, such as chlamydia, gonorrhea, syphilis, and trichomoniasis can all be treated and cured with antibiotics that are safe to take during pregnancy. Viral STDs, including genital herpes, hepatitis B, and HIV cannot be cured. However, in some cases these infections can be treated with antiviral medications or other preventive measures to reduce the risk of passing the infection to the baby. Detailed information on the management of specific infections during pregnancy can be found in CDC’s 2021 STI Treatment Guidelines.
STD Prevention during Pregnancy
After obtaining a sexual history from your patient, you should encourage risk reduction by providing prevention counseling. The most reliable way to avoid transmission of STDs is to abstain from oral, vaginal, and anal sex or to be in a long-term, mutually monogamous relationship with a partner known to be uninfected. For patients who are being treated for an STD other than HIV (or whose partners are undergoing treatment), counseling that encourages abstinence from sexual intercourse until completion of the entire course of medication is crucial. Latex male condoms, when used consistently and correctly, can reduce the risk of transmitting or acquiring STDs and HIV.
References
1. Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Eng TR, Butler WT, eds. Washington: National Academy Press. 1997.
2. Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2019. HIV Surveillance Report 2021;32.
3. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States.
4. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2021. Atlanta, GA: Department of Health and Human Services; April 2023.
5. Andrews WW, Goldenberg RL, Mercer B, Iams J, Meis P, Moawad A et al. The Preterm Prediction Study: association of second-trimester genitourinary Chlamydia infection with subsequent spontaneous preterm birth. Am J Obstet Gynecolo 2000;183;662-8.
6. Alger LS, Lovchik JC, Heel JR, Blackmon LR, Crenshaw Mc. The association of Chlamydia trachomatis, Neisseira gonorrhoeae, and group B streptococci with preterm rupture of the membranes and pregnancy outcome. Am J Obstet Gynecol 1988;159(2):397-404.
7. Genc M, Ledger WJ. Syphilis in pregnancy. Sex Transm Inf 2000;76:73.
8. Nelson DB, Macones G. Bacterial vaginosis in pregnancy: current findings and future directions. Epidemiolo Rev 2002;24(2):102-8.
9. Hauth JC, Goldenberg RL, Andrews WW, Dubard MB, Copper RL. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. N Engl J Med 1995;333:1732-6.
10. McDonald HM, O’Loughlin JA, Vigneswaran R, Jolley PT, Harvey JA. Impact of metronidazole therapy on preterm birth in women with bacterial vaginosis flora (Gardnerella vaginalis): a randomized, placebo controlled trial. Br J Obstet Gynecol 1997;104:1391-7.
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11. Morales WJ, Schorr S, Albritton J. Effect of metronidazole in patients with preterm birth in preceding pregnancy and bacterial vaginosis: a placebo-controlled, double blind study. Am J Obstet Gynecol 1994;171:345-9.
12. Cotch MF, Pastorek JG II, Nugent RP, Hillier SL, Gibbs RS, Martin DH, et al: Trichomonas vaginalis associated with low birth weight and preterm delivery. Sex Transm Dis 1997;24(6):353-60.
13. Hutto C, Arvin A, Jacobs R, Steele R, Stagno S, Lyrene R, et al. Intrauterine herpes simplex virus infections. J Pediatr 1987:110:97-101.
14. Sookoian S. Liver disease during pregnancy: acute viral hepatitis. Ann Hepatol 2006; 5:231.
15. Stevens CE, Toy PT, Tong MJ, et al. Perinatal hepatitis B virus transmission in the United States. Prevention by passive-active immunization. JAMA 1985; 253:1740.
16. Yeung LT, King SM, Roberts EA. Mother-to-infant transmission of hepatitis C virus. Hepatology 2001; 34:223.
17. Silverberg MJ, Thorsen P, Lindeberg H, Grant LA, Shah KV. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Obstet Gynecolo 2003;101(4):645-52.
18. Brown Z A, Wald A, Morrow R A, Selke S, Zeh J, Corey L. (2003) Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA, 289(2), 203-209.
19. American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. No. 82 June 2007. Management of herpes in pregnancy. Obstetrics and Gynecology, 2007. 109(6): 1489-1498.
20. Workowski, KA, Bachmann, LH, Chang, PA, et. al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70(No. 4): 1-187.
21. US Preventive Services Task Force. Screening for bacterial vaginosis in pregnancy to prevent preterm delivery: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;148:214-9.
22. Meites E, Gaydos CA, Hobbs MM, Kissinger P, Nyirjesy P, Schwebke JR, et al. Review of Evidence-based Care of Symptomatic Trichomoniasis and Asymptomatic Trichomonas vaginalis Infections. Clinical Infectious Diseases. 2015; 61:S837-48.
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